Provider Demographics
NPI:1467503185
Name:MEYER, MARK ALAN (MA, LP)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALAN
Last Name:MEYER
Suffix:
Gender:M
Credentials:MA, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 CARTER AVE
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1653
Mailing Address - Country:US
Mailing Address - Phone:651-426-1648
Mailing Address - Fax:
Practice Address - Street 1:6401 UNIVERSITY AVE NE
Practice Address - Street 2:SUITE 205
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4341
Practice Address - Country:US
Practice Address - Phone:651-426-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0244103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist